Defying Authority

How many of you have done that? Gone against the boss, the supervisor, or even just the advice of your best friend?

Being a physician, especially a cardiologist, can involve life and death decisions. Making those decisions as a first year intern often leads to white knuckle days and sleepless nights. Backup by a senior, more experienced mentor easies the responsibility. When the trainee disagrees with his mentor to follow his own instincts, he crawls far out on a limb. That can be pretty scary.

In my previous blog, I wrote about Dr. Walter Kempner and the rice diet that helped so many patients at Duke University Medical Center fifty years ago. In this blog, I will tell another Kempner story.

When we made rice rounds in the morning, an entourage of young doctors as well as several senior physicians employed by Kempner trailed behind. One doctor was an elderly woman who performed all the gynecology exams on Kempner’s female patients. We had just started rounds when she became ashen, sweaty, and complained of chest pain. She was immediately hospitalized and an electrocardiogram showed she had suffered a heart attack. Kempner asked me to take care of her.

Though the heart attack was mild, that afternoon her blood pressure fell to dangerous levels. She became short of breath, clammy and faded in and out of consciousness. I couldn’t figure out what was wrong until I realized she had been eating the rice diet with no salt. She needed saline to raise her pressure.

I explained her condition to Kempner. “No. Absolutely not. No salt,” was his emphatic response.

Toward early evening, she got sicker, but Kempner was adamant. Lab tests showed she was mildly anemic and I seized on that fact.

“Can I give her a transfusion?” I asked.

“Blood is okay. No salt.”

I infused a unit of blood and—directly disobeying his order—followed this with one liter of saline. Her blood pressure promptly rose, her clinical course stabilized, and she turned the corner.

I was a hero. That is, until the results of her urinalysis came back.

“Why is there so much salt in her urine?” Kempner demanded the next morning.

I flushed and fumbled for an answer. “Maybe she got salty blood, sir,” I stammered. He looked at me a long time, his penetrating dark eyes boring into my brain, knowing full well this was bullshit. I could see him weighing the situation and deciding what to do. A quick check of the patient’s chart would reveal my duplicity. Disobeying an order from the staff doctor was grounds for immediate dismissal from the training program, all my hopes and aspirations dashed. After an eternity he nodded briefly, spun around, and left. The rest of the gynecologist’s course was uneventful, and she returned to work soon after.